Postnatal transmission of HIV-1 associated with breast abscess

1490

idiopathic pancreatitis such as hyperlipidaemia and benign or malignant lesions of the ampulla of Vater, biliary tree, and pancreas. Endoscopic retrograde cholangiopancreatography is an essential investigation in the patient with idiopathic acute pancreatitis. Department of Surgery, University of Birmingham, Dudley Road Hospital, Birmingham B18 7QH, UK

J. P. NEOPTOLEMOS

1. Ros

E, Navarrs S, Bru C, Garcia-Puges A, Valderrama R. Occult microlithiasis in ’idiopathic’ acute pancreatitis: prevention of relapses by cholecystectomy or ursodeoxycholic add therapy. Gastroenterology 1991; 101: 1701-09. 2. Neoptolemos JP, Davidson BR, Winder AF, Vallance D. The role of duodenal bile crystal analysis in the investigation of "idiopathic" pancreatitis. Br J Surg 1988; 75: 450-53. 3. Lee SP, Nicholls JF, Park HZ. Biliary sludge as a cause of acute pancreatitis. N Engl J Med 1992; 326: 589-93. 4. Neoptolemos JP, Davidson BR, Vallence D, Winder AF. Bile-crystal analysis for the detection and type-identification of gallstones. Biochem Soc Trans 1987; 15: 1912-13. 5. Ramond M-J, Dumont M, Belghiti J, Erlinger S. Sensitivity and specificity of microscopic examination of gallbladder bile for gall recognition and identification. Gastroenterology 1988; 95: 1339-43. 6. Juniper K, Burson EN. Biliary tract studies II: the significance of biliary crystals. Gastroenterology 1957; 32: 175-209.

Kaposi’s sarcoma and faecal-oral

exposure

SIR,-Professor Beral and colleagues (March 14, p 632) provide evidence that Kaposi’s sarcoma (KS) among homosexual men is associated with active insertive "rimming" (oral-anal contact). This suggests that a sexually transmitted cofactor may be involved in the pathogenesis of AIDS-related KS. We investigated this hypothesis using data from the San Francisco Men’s Health Study, a prospective study of the epidemiology and natural history of AIDS in 1034 single men, 25-54 years of age, recruited by probability sampling from the nineteen census tracts of San Francisco with the highest cumulative incidence of AIDS in 1983. Participants have been interviewed and examined twice-yearly since 1984.1 Between 1984 and 1991, AIDS was diagnosed in 187 men, 87 (46-5%) of whom were diagnosed with KS at any time during follow-up. We found no association between differing proportions of sexual partners with whom respondents reported insertive rimming and the subsequent development of either KS or a non-KS AIDS-defining illness. These findings do not change when stratified by number of sexual partners, based on the median number of partners (20) in the 2 years before interview: AIDS but not

*Proportion of partners wIth whom respondent performed insertive rimming 2 years before 1984. With data from a 10-year, self-reported sexual behaviour questionnaire administered in 1985 we found that of 187 men who subsequently developed AIDS, 121 (65%) practised insertive rimming. Of these 121 men, 55 developed KS (45-5%) compared with 66 (54-5%) who were diagnosed with a non-KS AIDSdefining illness. Although surveillance data support the hypothesis that KS is a sexually transmitted disease in patients with HIV infection,2 data from San Francisco and two additional cohorts do not support the

hypothesis of faecal-oral contact or active rimming as risk factors for the sexual transmission of a putative KS agent.3,4 San Francisco Mens Health Study, University of California, Berkeley, School of Public Health, Berkeley, California 94720, USA

KIMBERLY PAGE-BODKIN JORDAN TAPPERO MICHAEL SAMUEL WARREN WINKELSTEIN

1. Winkelstein W, Lymn DL, Padian N, et al. Sexual practices and risk of infection by the human immunodeficiency virus: the San Francisco Mens’s Health Study. JAMA 1987; 257: 321-25. 2. Beral V, Peterman TA, Berkelman RL, Jaffe HW. Kaposi’s sarcoma among persons with AIDS: a sexually transmitted infection? Lancet 1990; 335: 123-28. 3. Lifson AR, Darrow WW, Hessol NA, et al. Kaposi’s sarcoma m a cohort of homosexual and bisexual men. Am J Epidemiol 1990; 131: 221-31. 4. Elford J, Tindall B, Sharkey T. Kaposi’s sarcoma and insertive rimming. Lancet 1992; 339: 938.

SIR,-Professor Beral and her colleagues suggest that non-sexual faecal contact, as associated with inadequate sanitation, might be an important means of transmission of the KS agent among HIVpositive heterosexuals in Africa. Should this be construed as suggesting that, contrary to an earlier hypothesis of sexual transmission/ epidemic (AIDS-related) KS in Africa may not be sexually transmitted? The idea, and presumed importance, of non-sexual contact with faeces in the transmission of the putative KS agent in Africa is not consistent with the epidemiology of epidemic KS. Epidemic KS has high incidence among young heterosexual adults of high socioeconomic class2 whose sanitary facilities and habits are good. The hypothesis would predict higher incidence in low socioeconomic groups, especially squatters, with poor sanitation; and clustering in settlements and suburbs (or even families) with inadequate sanitation. However, this is not the casez Even though endemic (non-AIDS related) KS has a higher incidence in low socioeconomic classes,2 its epidemiology3 is also not consistent with the hypothesis. I find the conclusion that the KS agent is transmitted mainly by contact with faeces rather overenthusiastic, for the reasons given above and for the fact that others have not found evidence to support the hypothesis.4,5 Although Beral et al suggest that, in retrospect, the decline in KS among homosexuals with AIDS may be due to decline in sexual practices involving contact with faeces (this reinforces their view), others4 have reported a similar decline in KS without a corresponding reduction in practices involving contact with faeces. Furthermore, a significant proportion of people with KS never had contact with faeces (either in studies supporting the hypothesis6 or in those that do not),5 and a significant proportion of those without KS nevertheless have had contact with faeces.4,6 I concur with Peterman and colleagues5 that if the putative agent of KS is sexually transmitted, its transmission may not be limited to the faecal-oral route. We do not yet have sufficient evidence for judgments about the importance of the faecal-oral route in the transmission of KS. Indeed, KS is so heterogeneous that until the exact relation between HIV/AIDS and the KS agent (and cofactors if any) is elucidated attempts to pursue a unitary aetiology or pathogenesis risk contributing to the elusiveness of this intriguing disease. University Teaching Hospital, Lusaka, Zambia

PATRICK MATONDO

1. Beral V, Peterman TA, Berkelman RL, Jaffe HW. Kaposi’s sarcoma among patients with AIDS: a sexually transmitted infection? Lancet 1990; 335: 123-28. 2. Bayley AC. Atypical aggressive Kaposi’s sarcoma in Africa. In: Gotlieb GJ, Ackerman AB, eds. Kaposi’s sarcoma: a text and atlas. Philadelphia: Lea & Febiger, 1988: 151-70. 3. Matondo P. Kaposi’s sarcoma epidemiology. Lancet 1992; 339: 939. 4. Elford J, Tindal B, Sharkey T. Kaposi’s sarcoma and insertive rimming. Lancet 1992; 339: 938. 5. Peterman TA, Friedman-Kien AE, Jaffe HW, Beral V. Kaposi’s sarcoma and exposure to faeces. Lancet 1992; 339: 685-86. 6. Darrow WW, Peterman TA, Jaffe HW, Rogers MF, Curran JW, Beral V. Kaposi’s sarcoma and exposure to faeces. Lancet 1992; 339: 685.

Postnatal transmission of HIV-1 associated with breast abscess SiR,—We have described 16 Rwandan mothers, out ofa cohort of 212 women followed up for a mean of 16 -months, in whom HIV-1 seroconversion was diagnosed post partum.1 9 of their 16 infants also seroconverted, all during the same 3-month period as the mother’s seroconversion. This suggested that HIV-1 could be transmitted postnatally from recently infected lactating mothers. Since that report, additional data from this cohort give a more precise view on the frequency of and risk factors for postnatal transmission. After a mean follow-up period of 26months (range 3-36) 2 new seroconverting mothers have been diagnosed (3-8 per 100 women-years for the first two years post partum; 95% CI 2-1-55). Both late seroconversions happened 24 months post partum in mothers who had stopped breastfeeding and the children remained seronegative up to the age of 36 months, confirming that close mother-to-child contact, with the notable exception of breastfeeding, is not associated with a substantial risk of transmission of HIV- 1.2 1 child described as uninfected in our original report (no 12 in fig 21) acquired HIV-1 infection 18 months after his mother’s

1491

SERIAL WESTERN BLOT (WB) AND DOUBLE POLYMERASE CHAIN REACTION (PCR) RESULTS IN MOTHER AND CHILD I

--

-

-

*WB positive If it showed at least three bands, one from each gene product group gag, pol, and env. tPosltive when there was a detectable signal, for at least two of three primer pairs directed to gag, pol, and env sequences.’

seroconversion (table). His mother was first shown to have HIV-1 antibodies at 12 months post partum. The child had three DNA

samples testing negative for HIV-1 specific sequences by double polymerase chain reaction at birth (cord blood) and at 3 and 18 months of life and was repeatedly HIV-1seronegative until the age of 30 months. At month 28 the mother had no HIV-1related signs symptoms but she had a severe breast abscess which required surgical treatment. Breastfeeding was stopped one week after the appearance of breast abscess. The child had HIV-1 antibodies (western blot) and HIV-1 -specific DNA sequences (PCR) at 30 and again at 36 months. At 36 months of age, he presented with generalised lymphadenopathy and persistent cough. Neither the mother nor the child had received blood transfusions or medical

The proportion of HIV tests that were confirmed positives fell from 32% in 1986 to around 10% in 1987-89, with individuals strongly self-diagnosing, and lower still to about 1% in 1990-91, with inmates now prompted to ask for the test because of a wider range of behaviours than just injecting. In mid-February, 1989, the prison’s AIDS education programme began: in the first weeks after detention in Saughton, all inmates are offered the opportunity of participation in the AIDS education programme and may request a voluntary named HIV test with pre and post test counselling by the prison medical service and a guarantee of the confidentiality of their test result. The 1989 total of 106 HIV test requests is significantly higher (by 2-85 SD, p < 005) than the mean number of tests requested in the other five years (mean= 67-2 requests, SD 13-6). Educational initiatives probably need to be updated periodically for their full impact to be substantiated. The number of confidential named HIV tests requested by Saughton inmates per month in 1991 was:

or

injections during follow-up. This additional case brings the rate of mother-to-child postnatal transmission of HIV-1in our cohort of lactating mothers to between 45% (5/11;95% CI 16-74%) and 60% (9/15; 95% CI 35-85%), taking or not taking into account seroconversions occurring in the first 3 months of life.1 The case reported here suggests that HIV-1 can be transmitted from mother to child during breastfeeding more than one year after the peak viraemia associated with recent maternal infection. The fact that HIV-1 acquisition by the child was temporally associated with a breast abscess suggests that ingestion of inflammatory cells (secondary to the breast bacterial infection) could contribute to postnatal transmission of HIV-1. If this observation is confirmed, HIV-1-infected mothers should be advised to abandon breastfeeding as soon as a breast abscess develops. In such circumstances the risk of transmission of HIV-1 could outweigh the risk of negative effects of artificial feeding, especially in children older than 18 months for whom breastfeeding carries little

advantage. AIDS Reference Laboratory, National AIDS Control Program, BP780 Kigali, Rwanda, Department of Paediatrics, Centre Hospitalier de Kigali; INSERM U 330, University of Bordeaux II,

PHILIPPEVAN DE PERRE DEO-GRATIAS HITIMANA ARLETTE SIMONON FRANÇOIS DABIS PHILIPPE MSELLATI ETIENNE KARITA Bordeaux, France; and Belgian-Rwandan Medical Cooperation PHILIPPE LEPAGE 1. Van de Perre P, Simonon A, Msellati P, et al. Postnatal transmission of human immunodeficiency virus type 1 from mother to infant: a prospective cohort study in Kigali, Rwanda. N Engl J Med 1991; 325: 593-98. 2. Hira SK, Nkowance BM, Kamanga J, et al. Epidemiology of human immunodeficiency virus in families in Lusaka, Zambia. J AIDS 1990; 3: 83-86.

Prisoners’ uptake of confidential, named HIV testing SIR,-We have reviewed the number (and result) of confidential, named HIV tests requested by male inmates of HM’s Prison, Saughton, in Edinburgh, between 1986 and 1991, to ascertain the impact of two interventions on HIV test uptake. The number of confidential named HIV test requests and the number that were HIV-1 antibody positive for the years 1986 to 1991 were as follows:

1986

was

the first year of HIV/AIDS information

promulgation.

In August, 1991, a voluntary anonymous HIV surveillance study conducted by external staff over two days (Aug 15 and 16).’ Three-quarters of 499 available inmates volunteered a saliva sample to be tested anonymously for HIV-1 antibodies and completed a linked risk-factor questionnaire. The August, 1991, total of 15 HIV test requests is significantly higher (by 2-87 SD, p < 0-02) than the mean number of tests requested in the other 11 months of that year (6-0 requests, SD 31). Moreover, the two tests requested on Aug 15 and 16 were five times the rest-of-year expectation of 0-40 tests per two days (SD 0-2). These data underscore that prisoners’ ready access to, and utilisation of, confidential named HIV testing is an ethical prerequisite in establishments in which it is proposed to conduct voluntary anonymous HIV surveillance. Such an intervention at Saughton was associated with greatly increased requests by prisoners for named HIV tests, August total for the years 1986-1991 having been 3, 5, 5, 10, 6, and 15. Saughton’s record of HIV tests suggests that high levels of voluntary, named HIV test uptake can be achieved in prisons. An inmate’s decision to take the blood test for HIV whilst incarcerated depends on: (1) awareness of personal risk factors; (2) general awareness of HIV disease, including its prevalence in the prison and in the community the prison serves; (3) awareness of the benefits of early diagnosis, for the individual2 and for contacts; (4) availability of test counselling by HIV-trained officers or prison medical staff; (5) trust that the result will remain confidential between inmate and prison medical staff, for as long as the inmate chooses and disease progression allows; (6) non-segregation of HIV-infected prisoners; (7) access to clinical management of HIV disease consistent with services available outside prison; (8) access to HIV support groups. Risk-factor elicitation in August, 1991,’ showed that 18% of Saughton inmates had at some time injected non-medically prescribed drugs; 15 % had had sex with six or more women in the year before sentence; and 6% of men acknowledged having paid money for sex. This behavioural profile identifies Saughton’s prisoners as being at increased risk of HIV disease. The prison’s known HIV prevalence in August, 1991, was 3-6%, whereas only 0-3% of all males aged 15-54 in Lothian region have been diagnosed as HIV-1 antibody positive. For these reasons, HIV test uptake within the prison cannot be compared directly with notifications to Communicable Diseases (Scotland) Unit. For all males aged 15-54 (the 1 43 million of Scotland’s population) 7921 HIV tests were notified in 1991, or 55 HIV tests per annum per 1000 males aged 15-54. We propose four statistics for inter-prison comparison of HIV test uptake-namely, tests per 1000 units of "certified normal accommodation" and of mean "Tuesday night lock-up figure" and tests per 1000 individuals admitted during the year and per 1000 admissions in the year. All four have their limitations but they are readily ascertainable for UK prisons and they would permit was